Q&A: What could be Causing my Penile and Perineum Pain?

…Should I Continue with Biofeedback and E-stim?

…If Kegels are bad, then what are we supposed to do for urine leakage?

…Why is yoga making my pelvic pain worse?

These are the reader questions we will be answering and in this Q&A blog post. So read on, and if you have any questions of your own, ask away in the comment section or shoot us an email at: [email protected].

What could be causing my penile and perineum pain?

Dear Liz,

I have experienced pelvic pain for the past two and a half years.  My symptoms are mainly burning in the perineum area and the penis. I do not have any post ejaculatory pain and in fact get some mild instant relief after ejaculation. I did see a pelvic floor PT for a year, but got minimal relief. My therapist found some tightness, but nothing significant and after a year, I don’t think there was much more she could do. There is one area where if I push deep enough on my perineum it does trigger a shocking feeling to my penis.  Any idea of what is going on?

Dear Reader,

It’s always hard to hypothesize about what is going on with someone without doing a comprehensive evaluation on him or her. With that said, it sounds like you may have some irritation of the dorsal branch of the pudendal nerve (it innervates the penis). If I were treating you, I would evaluate the muscle and connective tissue that surround that branch of the nerve to see if there are any impairments with them that could be causing nerve irritation.

There is a chance that the pelvic floor PT that you saw did not evaluate or treat those particular muscles since many pelvic PTs do not know how to access them in the male pelvic floor. That particular branch of the nerve travels in between the bulbospongiosus and ischiocavernosus muscles, so if they are tight they are going to compress and therefore irritate the dorsal branch of the pudendal nerve. In addition, the connective tissue medial to the inferior pubic rami (an area that is part of the front of your pelvic girdle) can compress the dorsal branch of the pudendal nerve. I can’t be sure that your pelvic PT evaluated this either since many pelvic floor PTs do not know how to do so. For either issue, manual, hands on PT is the treatment.

Should I Continue with Biofeedback and E-stim?

Dear Liz,

So far I’ve had three pelvic floor PT sessions for vaginismus. My urogynecologist referred me to PT because she said my muscles were tight and that is what is causing my issues.  At each of the sessions, my PT did only biofeedback and e-stim. After the first session, I felt like I saw improvement, but now I am not sure. After both the second and third sessions, when I urinated immediately after the session, I felt that my pelvic floor was tightening at the end of urination (as if I had a UTI).

Also, I’ve started to feel a burning sensation in my vagina. Despite this, my PT says I am showing progress because the biofeedback has gotten down to a “2” when I relax after doing the Kegels. But, I’m wondering how I can be showing progress with the biofeedback when I internally feel like I’m getting worse? Should I switch over to manual massage therapy or try to stick with the biofeedback/e-stim? I’ve only had three sessions, and I’ve heard that it’s the fourth or fifth session where patients see significant improvement.

Dear Reader,

It sounds like your pelvic floor muscles are indeed tight, therefore causing the urinary symptoms and the burning sensation in your vagina after the biofeedback/e-stim. For it’s part, e-stim causes your pelvic floor muscles to contract, which in turn is causing your already too tight muscles to tense up even further thus causing you to experience pain. As for biofeedback, from your description, it sounds as if the PT you are seeing is using the biofeedback incorrectly.

There are two appropriate uses for biofeedback in pelvic floor PT. One, is to “uptrain” or strengthen the pelvic floor if it’s truly weak or overstretched. The patient who might need biofeedback for this purpose likely has either incontinence or organ prolapse, not pain.

The other reason to use biofeedback is to help someone who has a tight pelvic floor learn how to relax his or her pelvic floor muscles. In this instance, a PT would insert the sensor and instruct patients on how to drop or relax their pelvic floor. Because they are getting visual feedback on their muscle activity from the biofeedback machine, the thinking is that patients can see for themselves when they are dropping their muscles. This visual feedback allows them to mentally note what it feels like when their muscles are dropped or relaxed or when they are too tight. The hope is that going forward the patients will be able to identify these feelings on their own without the sensor, and can relax their muscles at will when they are too tight.

While it’s okay to use the relaxation component of biofeedback on pelvic pain patients, it is not appropriate to use the strengthening/uptraining component on them. Here’s why: typically, if there is pelvic pain there are tight muscles and trigger points. Administering muscle strengthening/uptraining biofeedback under these circumstances will cause pelvic floor muscles that are already overly tight to further tighten thus causing further pain. Also, trigger points can be activated when tight muscles are made to tighten further. So in effect, the strengthening/uptraining biofeedback administered to the pelvic pain patient will simply serve to keep their cycle of pain intact.

In your email you said that you are “doing the Kegels” during your biofeedback sessions; therefore, I am assuming that your PT is using the biofeedback for uptraining because with uptraining muscle contracting a.k.a. Kegels are involved. If you have pelvic floor muscle tightness and/or pain, you should not do muscle contractions/Kegels! In the class we teach for PTs, and when we lecture, we constantly come across PTs who defend uptraining/ strengthening biofeedback and e-stim for use with pelvic pain patients who have tight pelvic floor muscles. Their argument is that the muscle contractions will cause the muscles to tire and thus ultimately relax. This line of thinking is completely misguided.

Here’s why: while this can occur with other muscles in the body—triceps or biceps for instance–it will not happen with pelvic floor muscles. The reason is that pelvic floor muscles are different from the other muscles in the body in that they are NEVER at a fully relaxed state. That’s because they have to hold up organs and keep us continent. Therefore, the theory that “if you tighten the muscles, they will tire and relax,” doesn’t fly with the pelvic floor. If this were the case, every time you tensed your pelvic floor, like with orgasm or even just when it’s cold outside, you’d be in danger of becoming incontinent.

As for the “progress” the biofeedback machine showed you when the measurements dropped down to a two, biofeedback alone should never be depended upon to determine if a patient’s muscles are tight or weak. That’s because when the muscles are tight, false readings are common. Manual, hands-on palpation of the muscles is the appropriate way to determine whether they are weak or tight or both.

I would discontinue the e-stim and biofeedback, and find a pelvic floor PT who does only hands-on, manual therapy. For further info on how biofeedback and e-stim are often misused in pelvic floor PT, you can check out this previous blog post: https://pelvicpainrehab.com/blog/2012/05/the-truth-about-biofeedback-and-e-stim/

If Kegels are bad, then what are we supposed to do for urine leakage?

Dear Stephanie,

If Kegels are not good for you, then what do you do to stop small amounts of urine leakage? I’m 51, and my doctor says that my bladder isn’t low enough for surgery.

Dear Reader,

To say that “Kegels are not good for you” is an over-simplification. The story is way more complicated. The issue is that both the medical community and society hound women to: “Do their Kegels!” This is irresponsible because for one thing, if someone has a tight pelvic floor or trigger points then doing Kegels is harmful because it makes already too tight muscles tighter and exacerbate trigger points. Plus, research has shown time and again that when women are told to “do kegels,” 40% of them do them incorrectly.

So Kegels are not across the board bad, but they are harmful to those with tight pelvic floors and trigger points. And telling a women to “just do Kegels” is likely not going to solve her problem if she has a weak or stretched out pelvic floor because many women will not do them correctly. Therefore, it’s best for a provider to show her how to do the contractions to ensure she is doing them correctly.

To address the second part of your question: “What should be done for urine leakage?” the best course of action is to go and see a pelvic floor PT for an evaluation so you can find out the status of your pelvic floor. For instance, if you have tight muscles or trigger points, the PT can first treat those impairments, and once they are corrected you can then  start a strengthening program, which will include contracting the pelvic floor, i.e. Kegels, without fear that you will cause a pelvic pain cycle to kick off, and with guidance from a PT so that you can be sure you are doing the Kegels correctly. In addition, the PT can give you a comprehensive home program for strengthening.

Lastly, and this is a very important point: there are other issues besides a weak pelvic floor that cause leaking, so by seeing a pelvic floor PT, you can find out exactly what is causing problem.

Why is Yoga making my Pelvic Pain Worse?

Dear Liz,

I am a 68-year-old man who has been a long-distance runner and bicyclist all my adult life. Two years ago I started having severe pelvic pain. Like most, I began treatment by a urologist and spent several months taking various antibiotics and pain medications and having invasive tests that revealed nothing. I then found an experienced PT who I trust and who has helped me tremendously.

Over time my condition has become quite manageable on two different occasions only to, for no apparent reason, relapse into severe, non-stop pain. I no longer cycle and my runs are now short, slow and increasingly infrequent. The exercise I do most regularly is yoga and stretching. This last relapse has now lasted several weeks and seems to be getting progressively worse instead of better, and I’ve been wondering if the yoga and stretching that I do might be contributing to this flare.

My understanding is that both should be very helpful long-term and, in the past, felt that stretching and yoga helped with the improvements I made in the past. But, with this latest pain flare, although they ease the pain immediately after I do them, a few hours later and lasting several days, they seem to make the pain more severe.

I am sort of stumped at where to go and what to do at this point. Any help you could give me would be much appreciated.

Dear Reader,

You should be careful with stretching/yoga because stretching muscles with active trigger points can actually exacerbate pain. Therefore, if you’re noticing increased pain after stretching/yoga, chances are you are stretching muscles with active trigger points. I would ask your PT which muscles in your pelvic girdle have active trigger points, and ask her what stretches/type of movement you should avoid until those trigger points are eliminated.

So that’s it for today dear readers! If you have any questions about any of the topics covered in this latest Q&A post, or if you have any questions of your own, please don’t hesitate to leave them in the comments section or email us at: [email protected].

All our very best,

Liz and Stephanie